Hematology: Peripheral blood smear

Anisocytosis

Variation in RBC size (normal 7-8 um)

Aniso: not same

Causes:

• Iron-deficiency anemia→ smaller cells

• Low Vit B12 (folate)→ larger cells

• Kidney/ liver disease

Hypochromia

RBCs paler than usual due to less hgb

Causes:

• Iron deficiency→ abnormal hgb

• Sideroblastic anemia→ BM cannot incorporate iron into hemoglobin properly

• Thalassemia→ Makes abnormal or less Hgb

• Chronic disease that interfere w/ iron use

Poikilocytosis

Distorted RBC shape in 10% or more of RBCs

Poikilo: Variable

Causes

• Sickle cell anemia→ crescent shaped

• Thalassemia→ bullseye shape

• Myelofibrosis (scar tissue buildup in BM)→ tear drop

• Iron deficiency→ oval, elonagated cells

• Mechanical damage→ fragmented cells

Pleocytosis

Increased Leukocytes in CSF (cerebrospinal fluid)

Pleo: plus, more

Causes:

• Central nervous system (CNS) infections such as meningitis or encephalitis

• Inflammatory autoimmune conditions like MS, systemic lupus

• Malignancy: cancers affecting CNS, leukemia/ lymphoma spreading to fluid

• Tissue damage

Types:

• Lymphocytic (mononuclear): Increased lymphocytes→ from viral/ fungal infections, or chonic inflammation

• Neutrophilic (suppurative): increased neutrophils→ from acute bacterial infection, or early non-infectious inflammation

Stomatocyte

Slit-like or “fish-mouth” central area of pallor in RBC

Stomato: mouth, opening

Causes:

• Lab artifact: if blood smear slide dries too slow

• Hereditary stomatocytosis: genetic membrane defects where RBC leak ions and water

• Acquired conditions: Alcoholic liver disease, medications, low pH

Hgb C crystals

Precipitated abnormal hgb C proteins inside RBC→ causes clumping

• Can be dense, rectangular

• or hexagonal rod-shaped

Caused by:

• Hemoglobin C Disease (HbCC): inherited homozygous autosomal recessive blood disorder (both genes)

• Hemoglobin SC Disease: one HbC and one sickle cell (HbS) gene

• Splenic function: spleen doesn’t properly filter them out (asplenia). Or doesn’t exist (splenectomy)

Drepanocyte

Sharp crescent, elongated RBC

Breaks down in 10-20 days→ leads to anemia

Drepano: sickle or crescent-shaped

Cause:

• Abnormal HbS.

  • When O2 drops, HbS forms stiff rods inside the cell→ curving it

Codocyte

Appeareance:

• Bullseye: dark center is hgb

• Bell shaped: under electron microscope

• Too much cell membrane

Causes:

• Liver disease: changes lipids in blood→ extra cholesterol to RBC walls

• Thalassemia: Abnormal form or not enough hgb

• Hemoglobinopathies: like HgC or HgS

• Iron deficiency anemia→ reduces Hgb in RBC

• Asplenia→ cannot clean out abnormal cells

Erythropoiesis nmemonic

PB in my PORES

Proerythroblast/ Normoblast

Basophilic erythroblast

Polychromatic erythroblast

Orthochromatic erythroblast

Reticulocyte

Normal RBC

What is this?

Pronormoblast/ Proerythroblast

From CFU-GEMM→ BFU-E (Burst-Forming Unit-Erythroid) → IL-3 trigger→ CFU-E→ EPO trigger→ Pronormoblast

• Nucleus takes up most of the cell

• 12-24um

• High N:C ratio

• 1-2 nucleoli

• Blue cytoplasm

• Golgi complex visible

• spread out chromatin

What’s this?

Basophilic erythro/normoblast

• ~20 hrs to develop

• 12-17um

• Chromatin clumps

• Accumulates more hgb and RNA

• Blue cytoplasm with pink RNA

• nucleus more compact

• Deep purple nucleus

What’s this?

Polychromatic erythro/normoblast

• ~30 hours to mature

• 10-15um

• Clumped/ condensed chromatin

• Blue hgb apparent in cytoplasm

• Pink RNA apparent in cytoplasm

• Nucleoli not visible

What’s this?

Orthochromatic erythro/ormoblast

• 48 hours to mature

• 8-10um

• Solid nucleus with clumped chromatin

• Nucleus moves to the side in preparation to be launched out

• Cytoplasm starts to be pink

• Cytoplasm has blue tint from Hgb

• No more DNA synthesis→ cannot divide

What’s this?

Polychromatophilic erythrocyte/

reticulocyte

• 115fL

• Nucleus gone but has RNA supravital stains

• Bluish cytoplasm

• 1-2 days circulation before maturing

• Released in 2-3 days

• Ribosomes disappear to make room for more Hgb

• Granulofilamentous ribosomes

• Has 2/3 of total Hgb

What’s this?

Mature erythrocyte

• 80-100fL

• No nucleus, mitochondria, ribosomes→ no more hgb synthesis

• Flexible to allow full passage of body

What’s this?

Myeloblast

From PSC→ IL-1,6,3 triggered→ Common myeloid progenitor (CMP)→ GM-CSF (granulocyte macrophage colony forming factor), IL-3 triggered→ CFU-GEMM→ GM-CSF, IL-3 triggered again→ CFU-G→ GM-CSF, IL-3 triggered again→ myeloblast

• 15-20um

• N:C ratio 6:1

• 1-3 nucleoli

• Oval, central nucleus

• Blue cytoplasm, no granules

• Chromatin red-blue mesh, no clumps

• Divides 3-5 times before next stage

• First recognizable cell

What’s this? (1,2,3)

Promyelocyte

• 12-24um

• N:C ratio 3:1

• Round-oval nucleus

• 1-2 nucleoli, fades w/ maturation

• Blue cytoplasm w/ azurophilic scattered granules (non specific)

• Mesh chromatin starting to aggregate at nuclear membrane

What’s this?

Myelocyte (neutrophilic)

GM-CSF (granulo monocytic colony stimulating factor), G-CSF (granulo colony stimulating factor) triggered

• 10-18um

• N:C ratio 2:1

• Nucleus oval or round, slight indent

• nucleus off center

• Nucleolus may have faded

• Cytoplasm blue-pink w/ azurophilic specific granules (secondary pink granules)

• Fine chromatin that’s red-blue. Starts aggregating, is granular

What’s this?

Metamyelocyte, neutrophilic

• 10-18 um

• N:C ratio 1:1

• Nucleus kidney shaped/ indented

• Nucleus central or off-center

• no nucleoli

• Cytoplasm clear pink w/ many neutrophilic granules

• Chromatin light blue-purple w/ basophilic chromatin

What’s this?

Neutrophilic band

• 10-16 um

• N:C ratio 1:1

• nucleus is horseshoe/ kidney shaped, central or off-center

• no nucleoli

• Cytoplasm pink with pink granules

• Chromatin purple red, clumped, pyknotic (shrinking and dark staining of chromatin)

What’s this?

Neutrophilic segmented

• 10-16um

• N:C ratio 1:3

• Nucleus is 2-5 individual lobes. Central or off-center

• Cytoplasm pink with pink fine granules

• Chromatin purple-red and clumped

What’s this?

Myelocyte, eosinophilic

GM-CSF, IL-5 triggered

• 10-18um

• N:C ratio 2:1

• Nucleus oval or round w/ indent. off-center

• may have nucleolus

• Cytoplasm blue-pink

• Uniform eosinophilic granules red-orange

• Chromatin red-blue, fine, starts to aggregate

?

Metamyelocyte, eosinophilic

• 10-18 um

• N:C ratio 1:1

• Nucleus kidney shaped (indented), central or off-center

• no nucleoli

• Cytoplasm clear pink cytoplasm, eosinophilic granules red-orange

• Chromatin light-blue purple and distinguishable basophilic chromatin

?

Eosinophilic band

• 10-16 um

• N:C ratio 1:1

• Nucleus elongated, central or off-center

• no nucleoli

• Cytoplasm pink w/ red eosinophilic granules

• Chromatin coarse blue-purple

?

Eosinophilic segmented

• 10-16 um

• N:C Ratio 1:3

• Nucleus has two lobes (bilobed) thinly connected by chromatin

• Cytoplasm pink, granules red and uniform

• Chromatin is blue and granular

?

Myelocyte, basophilic

IL-3/ IL-4 triggered

• 10-18um

• N:C ratio 2:1

• Nucleus oval/ round, slight indent, off-center

• May have nucleous

• Cytoplasm blue-pink, granules non-uniform and coarse basophilic

• Chromatin red-blue, fine, begins aggregating

?

Basophilic metamyelocyte

• 10-18um

• N:C ratio 1:1

• Nucleus kidney shaped, central or off-center

• no nucleoli

• Cytoplasm pale blue, granules coarse blue-violet

• Chromatin light blue-purple

?

Basophilic band

• 10-16um

• N:C ratio 1:1

• Nucleus sausage-shaped, central or off-central

• no nucleoli

?

Basophilic segmented

• 10-16 um

• N:C ratio 1:3

• Nucleus has 2 lobes, central or off-center

• Cytoplasm light blue, granules coarse blue-violet

• Chromatin coarse purple

?

Megakaryoblast

CMP→ GM-CSF, IL-3 triggered→ CFU-Meg→ GM-CSF, IL-3 triggered→ megakaryoblast

• 20-45 um

• N:C ratio 5:1-3:1

• Nucleus round/ oval/ kidney-shaped, central or off-center

• 1-2 nucleoli

• Cytoplasm basophilic, nongranular

• Pseudopodium (cytoplasm has protrusions)

• Chromatin red-purple

?

Promegakaryocyte

• 20-89 um

• N:C ratio is 3:1-5:1

• Nucleus is round/ oval/ kidney-shaped, central or off-central

• 0-2 nucleoli

• Cytoplasm basophilic, with many pseudopodia

• Granules are fine, azurophilic

• Chromatin red-purple w/ increased granularity

?

Megakaryocyte

• 30-100um

• N:C ratio 1:1-1:2

• Nucleus has 2+ lobes

• Cytoplasm pale blue-pink

• Granules fine, azurophilic

• Chromatin purple-blue, granular

• No nucleoli

?

Thrombocyte/ platelet

• 1-4um

• Cytoplasm light blue

• Granules red-blue, evenly dispersed